Warning issued about tubing misconnections.

The Institute for Safe Medication Practices (ISMP) has issued an alert about life-threatening tubing misconnections in commonly used medical equipment. Errors such as oxygen tubing being accidentally connected to needleless or standard IV tubing continue because many tubing "attachment" sites look similar and because all medical gasses and most fluids are clear, making it virtually impossible to distinguish between them when observed through transparent medical tubing, suggests the ISMP. To reduce the risk of errors, the ISMP recommends the following:

* Review the medical equipment used in the facility to identify the potential for misconnections to IV tubing.

* Educate all staff, including nonclinical employees who work in patient care units, about this potential hazard.

* Require staff to completely trace tubing from the patient to the point or origin for verification before tubing is connected or reconnected to a patient.

* Appropriately label IV lines.

* Identify all staff who may manipulate various forms of tubing attached to patients, and consider whether that falls within their scope of practice; make it clear during orientation who should be performing those tasks and who should not, and offer practice in turning down requests by unqualified personnel to manipulate medical tubing.

For a copy of an ISMP newsletter article on tubing misconnections, visit www.ismp.org/MSAarticles/tubing.htm.